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Inspection on 11/04/08 for Drummuir Nursing and Residential Home

Also see our care home review for Drummuir Nursing and Residential Home for more information

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The company have been proactive in ensuring that the service is effectively managed in the absence of a registered manager. The company have implemented improvements in line with their improvement plan. Visitors to the home confirmed that they are always made welcome.

What has improved since the last inspection?

A Pre admission assessment is now completed on all prospective people using the service and includes emergency admissions. This is to ensure that the home can meet all the identified needs of the service user prior to admission. The home now ensures that all care plans are completed within an appropriate timescale to ensure that staff can identify all care needs and follow an agreed plan of care. The detail contained and review of care plans was seen to have significantly improved. The home now has a procedure which provides a clear indication on the Medication Administration Records were the prescribed creams are to be signed for as administered. All records are now stored in line with the Data Protection Act 1988. The home appeared clean and had no further malodour. The home had undertaken further redecoration and new carpets have been laid in the stairwells and lounge.

What the care home could do better:

The Manager Designate is recommended to review the provision of contracts to ensure that each person admitted to the home received a contract to clarify the terms and conditions of residency. The Manager Designate is recommended to record with 2 signatures the disposal of unused medication to ensure there is no risk of incorrect recording and loss of medication. The Manager Designate must ensure that the home receives 2 suitable references for each prospective member of staff prior to commencing employment, one of which must be the previous employer.Any gaps in employment history must be investigated and the reasons documented. This action is required to ensure that people using the service are not placed at risk of abuse. The Manager Designate is recommended to obtain the current updated copy of the Safeguarding Vulnerable Adults Policy for Somerset to ensure that staff are aware of the action to be taken should an allegation of abuse be made. The Manager Designate is recommended to review the security of the home to prevent unauthorised access, which may place people using the service at risk. The Manager Designate is further recommended to ensure that all bathrooms, sluice and equipment stored within them are cleaned and do not present a possible risk of cross infection. The manager designate is recommended to ensure that a minimum of 50% of staff have achieved an NVQ level 2 qualification to ensure a good standard of training for all staff.

CARE HOMES FOR OLDER PEOPLE Drummuir Nursing & Residential Home 9-11 Northfield Bridgwater Somerset TA6 7EZ Lead Inspector Gail Richardson Key Unannounced Inspection 11th April 2008 08:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Drummuir Nursing & Residential Home Address 9-11 Northfield Bridgwater Somerset TA6 7EZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01278 422144 01278 420397 www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Caroline Williamson Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Elderly persons of either sex, not less than 60 years, who require general nursing care Up to two persons of either sex, between the ages of 50-60 years who require general nursing care Up to eight places for personal care Date of last inspection 11th December 2007 Brief Description of the Service: Drummuir Nursing Home is situated in a quiet residential area close to the town centre of Bridgwater, Somerset. The home is not purpose built. Drummuir is registered with the Commission for Social Care Inspection to provide general nursing care for up to 38 older people, although the home can only accommodate a maximum of 31 service users. This includes up to 8 service users who require personal care. There is a registered general nurse on duty at all times. The home has recently been taken over by Southern Cross Healthcare and has had a new manager in place. The fee range is between £522.00 and £577.00; this does not include hairdressing, newspapers, toiletries, optician and some activities not provided by the home. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection, which took place over 1 day (5.30 hours) on the 11th April 2008 by inspector Gail Richardson. A tour of the home took place and a selection of the bedrooms and the communal areas were seen. There were 27 people currently residing at the home, with one person receiving personal care only. The inspector spoke to 4 people using the service, 1 visitor and 8 members of staff, the Manager Designate and the Deputy Manager were available throughout the inspection. As part of this inspection the inspector surveyed the opinions of a random selection of people using the service and their representatives, GP’s, District Nurses and Care Workers. Surveys were sent to people using the service and moderate levels of responses were received. The inspector spent time talking to people within the home, a visitor and staff and observed that on the day of inspection, residents appeared comfortable in all areas of the home. Staff were happy to tell the inspector that they enjoyed working at the home and felt that staffing was currently settled. Records relating to care including 4 care plans, 2 staff file and health and safety records were examined. The focus of this inspection visit was to inspect relevant key standards under the CSCI ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Manager Designate is recommended to review the provision of contracts to ensure that each person admitted to the home received a contract to clarify the terms and conditions of residency. The Manager Designate is recommended to record with 2 signatures the disposal of unused medication to ensure there is no risk of incorrect recording and loss of medication. The Manager Designate must ensure that the home receives 2 suitable references for each prospective member of staff prior to commencing employment, one of which must be the previous employer. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 7 Any gaps in employment history must be investigated and the reasons documented. This action is required to ensure that people using the service are not placed at risk of abuse. The Manager Designate is recommended to obtain the current updated copy of the Safeguarding Vulnerable Adults Policy for Somerset to ensure that staff are aware of the action to be taken should an allegation of abuse be made. The Manager Designate is recommended to review the security of the home to prevent unauthorised access, which may place people using the service at risk. The Manager Designate is further recommended to ensure that all bathrooms, sluice and equipment stored within them are cleaned and do not present a possible risk of cross infection. The manager designate is recommended to ensure that a minimum of 50 of staff have achieved an NVQ level 2 qualification to ensure a good standard of training for all staff. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 2 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides prospective residents and relatives with sufficient information in the format of brochures, the Service User Guide and Statement of Purpose for them to make an informed decision about the home. All prospective people using the service receive a pre admission assessment to ensure the home can meet the assessed needs identified. Contracts were not available for all people using the service. EVIDENCE: 9 people using the service surveys were returned to the inspector and 5 of these confirmed that they received enough information prior to admission and 4 did not. Comments received included; Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 10 ‘No information given just moved by relatives’ ‘No information given, happy at last place, got put in here by relatives’ 5 Residents surveys received stated that they had received a contract and 4 had not. The inspector requested the contracts for the 3 people whose records were examined in detail. The home was not able to provide contracts for 2 of those. It was discussed that contracts are required to be issued on admission to ensure that people have a clear understanding or their terms of residency. The home provides a Statement of Purpose and Service User Guide, which is comprehensive and details the ongoing changes to the home. The guide had been updated to reflect the recent appointment of a new Manager Designate. This updated copy was displayed within the home. The inspector examined three care plans all of which included a pre admission assessment and SAP assessment, there was evidence of family involvment in the admission process. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person using the service has a care plan, the assessed areas of need were reflected in this plan of care and the detail recorded ensured that staff would be advised of all the areas of need. The management of medications systems was of a good standard. Staff were observed to treat service users with dignity and respect at all times and people confirmed that they felt well cared for. EVIDENCE: The inspector examined 4 Care plans. All 4 care plans included risk assessments for nutrition, pressure risk, falls and dependency. There was evidence of health professional input in the care plan process and regular reviews of care. The inspector noted a significant improvement in the quality and detail of the care plans examined. The assessed needs of each person were reflected in a Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 12 detailed plan of care ensuring that staff had a regularly reviewed and updated plan of care to work from. Short-term care needs were noted to be included. The input of the person and their relative was also included in some cases. This practice is recommended to be widened to ensure that wherever possible all people using the service and their relatives are involved in the care planning process. A daily record of care was seen for each person and records were maintained of visiting health professional input. The deputy manager is auditing all wounds to ensure a regular review of care given and changes made as required. The improvement in care planning is to be commended. When people using the service were asked do you receive the care and support you need, 6 surveys said always and 3 said usually, 1 said sometimes. 8 responded that staff listen and act on what the residents say and 1 said no, all 9 felt they received the medical support they needed. When asked do the staff listen and act on what you say, 8 -yes and 1 -no. Comments received from people using the service included; ‘The staff are looking after me well, I have no problems, they are trying to sort me out’ ‘Mostly not all the time depends who it is’ ‘They look after me very well’ ‘I feel that when I am in the lounge there should be more call bells available’ ‘The nurses are very kind to me’ The people using the service observed by the inspector appeared comfortable and settled. There was evidence of use of pressure relieving equipment and equipment was provided to support mobility. The inspector observed staff interaction with people using the service during inspection and observed that people using the service were treated with dignity and respect at all times. Staff were observed to behave in a courteous manner. The medication systems were assessed to be of a good standard. The deputy manager appears to have clear systems in place for ordering, administration, disposal and auditing of medication records. The Deputy manager has implemented a system to record the administration of all prescribed creams and dietary supplements, all are recorded on the Medication Administration Records as given. The Manager Designate is recommended to record with 2 signatures the disposal of unused medication to ensure there is no risk of incorrect recording and loss of medication. People using the service have the option to self medicate should they want to but nobody is self-medicating at the moment. Lockable storage is available as required. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 13 A homely remedy policy is in place with signed consent on agreed protocols by the relevant GP’s. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a range of opportunities for social stimulation which is recommended for further development, people using the service are supported to join in with some activities organised by care staff or pursue their own interests. Visitors are welcome throughout the day. The meals in the home are of a good quality and a wide range of choice is available. EVIDENCE: People using the service surveys asked are there activities arranged by the home that you could take part in, 5 -always, 2-usually, 0-sometimes, 1- never. One comment received was; ‘I don’t take part in activities very often but that doesn’t mean there not there to do’. The Manager Designate confirmed that the home is currently without a trained activity coordinator and advertisements are in place. The care staff have a loose plan of activities, which are undertaken depending if the workload allows. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 15 A notice board is in place in the dining room and front hall outlining planned activities. No activities were seen on the day of inspection but a person was able to confirm that bingo had taken place the day before. During the inspection visitors were seen to be welcomed to the home and had access to the lounge and people using the service bedrooms. One visitor confirmed that they were made welcome at anytime. The inspector spent time talking with people using the service and observed people reading and chatting to staff and visitors. It was noted that upon arrival to the home the inspector found the front door to be open and no staff available for over 5 minutes. The security of the home must be reviewed to ensure the safety and security of people using the service and for the support of visitors to the home. The home has access to an independent advocacy service and all people using the service are registered to vote. People using the service’s rooms were decorated in a manner, which reflected their tastes and lifestyles. Evidence was seen in some cases of people’s own furniture in their bedrooms. The menu is available in the main foyer of the home, on the day of inspection lunch was Beef Casserole or beef burgers with mashed potato, peas and swede with plumb crumble for desert. The evening meal was a mixture of party food including sausage rolls, sandwiches, quiche and salad. The lunchtime meal was served hot and appeared plentiful and appetising, people using the service confirmed that they enjoyed the food and that choice was always available. Specialist diets are catered for and all pureed food is served individually. Menus are set by the cook to include the preferences and choices of people using the service. Staff were available to assist people using the service with eating and drinking and were seen to do so in a discreet and appropriate manner. Resident’s surveys asked if residents like the meals at the home, 5-always, 3.usually and s said sometimes. One person told the inspector that the quality of the food was ‘off and on’. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff and people using the service are aware of how to raise any complaints or concerns. Policies, procedures and training are available to staff to ensure they have the knowledge to prevent service users from the risk of abuse. Further updated procedure regarding Adult Protection Policy is recommended. Recruitment procedures protect people using the service from the risk of abuse. EVIDENCE: The complaints policy is displayed in the entrance to the home and describes clearly the action to take should a complaint be made and is clear about the response you would receive. No complaints have been received by the home or CSCI since the previous key inspection. 1 relatives surveys and 7 people using the service surveys, confirmed that they knew how to make a complaint, 2 did not and some but not all surveys confirmed that people knew who to speak to if they were unhappy. Comments from people using the service included; Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 17 ‘I don’t know how to complaint, I don’t need to make a complaint because I am very grateful’ ‘I know how to make a complaint but feel it doesn’t go anywhere’ All staff are trained through induction and on going training is provided, staff confirmed that training is ongoing and notices in the home advertised further training dates for Dementia Awareness and Challenging behavior training. Policies are available to support staff with regard to complaints, abuse awareness and whistle blowing. The policies need to be updated to include the most recent Adult Protection Policy for Somerset to ensure that staff are all aware of the actions to be taken should an allegation of abuse be made. 2 staff files were examined and the Manager Designate confirmed that both staff had commenced employment following receipt of a Protection of Vulnerable Adults check and were supervised until they had received their Criminal Record Bureau Check. This supervision is recorded on the staff rota. It was noted that both staff had not received 2 references; on both occasions only one had been received. This practice is required to reviewed immediately and staff must receive 2 suitable references prior to commencing employment. One of those references must be from the most recent employer. It was also discussed with the manager designate that during the recruitment process that all prospective staff are recommended to provide an employment history for the previous 10 years to ensure that people using the service are not at any risk of abuse. Any gaps must be investigated and the reasons documented. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Maintenance of the home is seen to be ongoing with development of areas to meet the needs of the people using the service; the standard of hygiene is adequate. Appropriate equipment is made available were there is an assessed need. The gardens are laid out and suitable for people using the service use. EVIDENCE: The home is a large older building, which has been converted and extended. There is a communal lounge and dining area, these are adequately furnished and decorated. The lounge and stair carpets have been replaced and a new kitchen window has been fitted. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 19 Personal accommodation is located on each of the 3 floors of the home and is accessible to people with all levels of mobility. Lift access is available to each floor. All bedrooms seen by the inspector varied in size and were comfortably furnished and had been personalised to reflect the tastes of the individual person. People are able to bring personal effects and small items of furniture with them when they move to the home, which gives rooms an individual homely feel. The hot water system has been reviewed and all hot water outlets tested appeared to have sufficient hot water. Various aids and adaptations have been put in place to assist people to maintain their independence. Specialist pressure relieving cushions and mattresses were seen were there was an assessed need. Profile beds have been provided for people with nursing needs. Toilet and bathing facilities are provided in sufficient numbers and the development of a ‘wet’ room is almost completed. The bathroom on the ground floor appears to be used as storage for hoists, these hoist are in need of cleaning as appear splashed and dirty. The bathroom also appeared unclean. The upper floor sluice is also in need of repair to prevent the risk of cross infection. Other areas of the home appeared to have a satisfactory standard of hygiene with no malodour. The garden area is maintained and accessible for people using the service. There is a small pagoda area, which is currently used as a staff smoking area. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Evidence supplied would suggest that staffing levels do not always meet the dependency of the people using the service. Staff training is ongoing and all staff undertake mandatory and further training. The homes recruitment procedures are adequate. Further checks are required to ensure the system is robust and protect people using the service from the risk of harm. EVIDENCE: Evidence from residents and relatives surveys would indicate that staffing levels at the home are variable. On duty in the day of inspection were The Manager Designate (on Induction), The deputy manager, 5 care staff, 1cook, 1 kitchen assistant, 2 cleaners, 1 housekeeper and a handyperson. It was observed that one care staff left the home on escort duty to the hospital. On observation staff appeared busy and appeared to be working well Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 21 together as a team, the inspector observed staff reorganising their workload to ensure people needing care had their needs met as soon as possible. Comments received from surveys included; ‘All depends on if the home is short staffed I am generally happy with the care but occasionally can be poor depending on staff’ ‘The carers do their best and are very busy seeing to everyone. I feel they need more carers as they are overworked’ Staff commented; ‘Short notice sickness hard to cover as sometimes, no agency available either’ ‘We try our best at all times’ Staff rotas examined confirmed that there was usually 1 qualified nurse and 5 care staff each morning and 1 qualified and 4 care staff in the afternoons. It was noted that at the weekends the staff numbers dropped in the mornings to 1 qualified nurse and 4 care staff and the afternoons to 1 qualified nurse and 3 care staff. The staffing levels must be reflective of the dependency levels of people using the service at all times. Staff and records confirmed that a comprehensive induction and mandatory training is completed and further specific update training is provided which included Bed rail safety, Dementia Care and Challenging behaviour are also planned. The home employs an in house trainer who updates all mandatory training and also uses the Skills for Care program. The staff-training matrix supplied would indicate that less than 50 of staff have completed NVQ training. It is recommended that further NVQ training is provided to ensure that above 50 of staff are qualified to this level. Staff records and staff comments confirmed that they receive regular one to one supervision to discuss further training needs and any ongoing concerns in the home. Staff confirmed that regular staff meetings take place as an opportunity for group discussion. 2 recruitment files of the most recently recruited staff were examined. The recruitment procedures were mostly complete. It was observed that 2 staff commenced employment with only 1 reference received, POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) check having been received. The home had undertaken staff induction training prior to those checks being received but the Manager Designate confirmed that at this time staff had no contact with people using the service. Both records evidenced some gaps in employment history. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 22 The Commission recommends a 10-year employment history to be requested and any gaps explored and documented to ensure people using the service are not put at risk. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 35 36 37 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Financial systems for people using the service personal monies are managed in an auditable manner. The storage of records is secure and in line with the Data Protection Act. Systems are in place to ensure the health and safety of service users whilst encouraging and promoting independence. EVIDENCE: The home has recently recruited a new Manager Designate; as a result standards 31 and 32 will not be assessed at this inspection. Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 24 Quality assurance questionnaires were not available at this inspection. The home is recruiting new administrative staff the Manager Designate confirmed that the quality assurance procedure will be available at the next inspection. There are established systems in place for dealing with people using the service personal finances. The inspector evidenced that each person’s personal monies were recorded and receipts checked. All accounts are held by the company’s accounts and a float of accessible cash maintained for people using the service to access should they need any money. An invoice of cash flow by each person was sent with the fee request each month. All records are stored confidentially in line with the Data Protection Act. Security of documentation had improved since the previous inspection. All substances hazardous to health were seen to be stored securely and staff confirmed that had access to COSHH sheets should they need them. Accident records were viewed and were seen to be reviewed and audited monthly for trends and regular occurrences and action taken to reduce any risks of further accidents taking place. The last audit was March 2008. Maintenance records were well maintained and up to date, these included; * Fire Extinguishers last tested 28/02/08 * Fire alarms are tested weekly 07/04/08 * Fire Alarm servicing 28/02/08 * Hoist servicing last undertaken 20/11/07 * Emergency lighting checked monthly April 2008 * Boiler servicing and repair 11/12/07 * Lift servicing records last undertaken 28/08/07 * Hot water temperatures are being monitored monthly last checked March 2008 * Electrical Hard Wiring certificate 29/06/06 * Accident audit is ongoing monthly * Nurse call system 28/02/08 Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 3 3 3 Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP18 Regulation 12(1)(a) Requirement The Registered person must ensure that all staff receive 2 suitable references, one of which must be the previous employer prior to commencing employment Any gaps in employment history must be investigated and the reasons documented. 2. OP27 18(1)(a) The registered person is required to ensure that staffing levels are calculated by the dependency levels of the Service users. Previous timescale not met 01/01/08 01/05/08 Timescale for action 01/05/08 Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations The registered person is recommended to review the provision of contracts to ensure that each person admitted to the home received a contract to clarify the terms and conditions of residency. The registered person is recommended to record with 2 signatures the disposal of unused medication to ensure there is no risk of incorrect recording and loss of medication. The activity coordinator is recommended to ensure that the choices, preferences and abilities of service users are considered when activities are planned. The registered person is recommended to review the security of the home to prevent unauthorised access, which may place people using the service at risk. The registered person is recommended to obtain the current updated copy of the Safeguarding Vulnerable Adults Policy for Somerset. The registered person is recommended to ensure that all bathrooms, sluice and equipment stored within them are cleaned and do not present a possible risk of cross infection The registered person is recommended to ensure that a minimum of 50 of staff have achieved an NVQ level 2 qualification. 2. OP9 3 OP12 4. OP13 5 OP18 6. OP26 7. OP28 Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Drummuir Nursing & Residential Home DS0000065814.V360534.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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